Case Studies volume 1

9780521182089

Describes a wide-ranging and representative selection of clinical scenarios. The book is about living through the treatments that work, the treatments that fail, and the mistakes made along the journey. This is psychiatry in real life - these are the patients from your waiting room - this book will reassure, inform and guide better clinical decision making.

Case Studies: Stahl's Essential Psychopharmacology: CME Information

Release/Expiration Dates

CME credit expiration date: April 30, 2014. (CNE credit expires April 30, 2013). If either of these dates has passed, please contact NEI for updated information.

Overview

This book is a series of case studies in psychiatric disorders, all adapted from real
practice, that provide a glimpse into what cases look like after the first consultation
and over time, living through the treatments that work, the treatments that do not
work, the mistakes, and the lessons to be learned.

Target Audience

This activity has been developed for prescribers specializing in psychiatry. There
are no prerequisites for this activity. Health care providers in all specialties who
are interested in psychopharmacology, especially primary care physicians, nurses,
nurse practitioners, psychologists, and pharmacists, are welcome for advanced study.

Statement of Need

The content of this educational activity was determined by critical analysis of activity
feedback, expert faculty assessment, literature review, and new medical knowledge,
which revealed the following unmet needs:

Mental disorders are highly prevalent and carry substantial burden that can be alleviated
through treatment; unfortunately, many patients with mental disorders do not receive
treatment or receive suboptimal treatment

There is a documented gap between evidence-based practice guidelines and actual care
in clinical practice for patients with mental illnesses

This gap is due at least in part to lack of clinician confidence and knowledge in
terms of appropriate usage of the diagnostic and treatment tools available to them

In order to improve outcomes for patients with psychiatric disorders, NEI will provide
education regarding the following as one means to address clinician performance deficits
with respect to diagnosis and treatment of mental disorders

Diagnostic strategies that can aid in the identification and differential diagnosis
of patients with psychiatric illness

Integrate novel treatment approaches into clinical practice according to best practice
guidelines

Assess treatment effectiveness and make adjustments as needed to improve patient outcomes

Accreditation and Credit Designation Statements

The Neuroscience Education Institute is accredited by the Accreditation Council for
Continuing Medical Education to provide continuing medical education for physicians.

The Neuroscience Education Institute designates this enduring material for a maximum
of 67.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation
in the activity.

The American Society for the Advancement of Pharmacotherapy is approved by the American
Psychological Association to sponsor continuing education for psychologists. The American
Society for the Advancement of Pharmacotherapy maintains responsibility for this program
and its content.

The American Society for the Advancement of Pharmacotherapy designates this program
for 67.0 CE credits for psychologists.

This continuing nursing education activity has been submitted for approval to ANA-MAINE,
an accredited approver by the American Nurses Credentialing Center’s Commission on
Accreditation.

Note to Physician Assistants: the AAPA accepts AMA PRA Category I Credit™ from organizations accredited by the ACCME.

Also available will be a certificate of participation for completing this activity.

Activity Instructions

This CME activity is in the form of a printed monograph and incorporates instructional
design to enhance your retention of the information and pharmacological concepts that
are being presented. You are advised to go through each case from beginning to end,
including the brief tutorial at the end of each case, and then complete the posttest
and activity evaluation. The estimated time for completion of this activity is 67
hours.

Instructions for CME Credit

To receive a certificate of CME credit or participation, please complete the posttest
and commitment-to-change questions along with the activity evaluation, available online
only at www.neiglobal.com/CME(under “Book”). If a passing score of 70% or more is attained (required to receive
credit), you can immediately print your certificate. There is a fee for CME credits
for this activity (waived for NEI members).

NEI Disclosure Policy

It is the policy of the Neuroscience Education Institute to ensure balance, independence,
objectivity, and scientific rigor in all its educational activities. The Neuroscience
Education Institute takes responsibility for the content, quality, and scientific
integrity of this CME activity.

All faculty participating in any NEI-sponsored educational activity and all individuals
in a position to influence or control content development are required by NEI to disclose
to the activity audience any financial relationships or apparent conflicts of interest
that may have a direct bearing on the subject matter of the activity. Although potential
conflicts of interest are identified and resolved prior to the activity, it remains
for the audience to determine whether outside interests reflect a possible bias in
either the exposition or the conclusions presented.

Individual Disclosure Statements

Author/Developer

Stephen M. Stahl, MD, PhD

Adjunct Professor, Department of Psychiatry, University of California, San Diego School
of Medicine

Disclosed financial relationships have been reviewed by the Neuroscience Education
Institute CME Advisory Board to resolve any potential conflicts of interest. All faculty
and planning committee members have attested that their financial relationships do
not affect their ability to present well-balanced, evidence-based content for this
activity.

Disclosure of Off-Label Use

This educational activity may include discussion of unlabeled and/or investigational
uses of agents that are not approved by the FDA. Please consult the product prescribing
information for full disclosure of labeled uses.

Disclaimer

Participants have an implied responsibility to use the newly acquired information
from this activity to enhance patient outcomes and their own professional development.
The information presented in this educational activity is not meant to serve as a
guideline for patient management. Any procedures, medications, or other courses of
diagnosis or treatment discussed or suggested in this educational activity should
not be used by clinicians without evaluation of their patients’ conditions and possible
contraindications or dangers in use, review of any applicable manufacturer’s product
information, and comparison with recommendations of other authorities. Primary references
and full prescribing information should be consulted.

Sponsorship Information

Sponsored by the Neuroscience Education Institute.

Additionally sponsored by the American Society for the Advancement of Pharmacotherapy.

Support

This activity is supported solely by the sponsor, Neuroscience Education Institute.

Case Studies: Stahl's Essential Psychopharmacology: Introduction

Joining the Essential Psychopharmacology series here is a new idea – namely, a case book. Essential Psychopharmacology started in 1996 as a textbook (currently in its third edition) on how psychotropic drugs work. It then expanded to a companion Prescriber’s Guide in 2005 (currently in its fourth edition) on how to prescribe psychotropic drugs. In 2008, a website was added (stahlonline.org) with both of these books available online in combination with several more, including
an Illustrated series of several books covering specialty topics in psychopharmacology. Now comes
a Case Book, showing how to apply the conceptspresented in these previous books to real patients in a clinical practice setting.

Why a case book? For practitioners, it is necessary to know the science of psychopharmacology
– namely, both the mechanism of action of psychotropic drugs and the evidence-based
data on how to prescribe them – but this is not sufficient to become a master clinician.
Many patients are beyond the data and are excluded from randomized controlled trials.
Thus, a true clinical expert also needs to develop the art of psychopharmacology:
namely, how to listen, educate, destigmatize, mix psychotherapy with medications and
use intuition to select and combine medications. The art of psychopharmacology is
especially important when confronting the frequent situations where there is no evidence
on which to base a clinical decision.

What do you do when there is no evidence? The short answer is to combine the science
with the art of psychopharmacology. The best way to learn this is probably by seeing
individual patients. Here I hope you will join me and peer over my shoulder to observe
40 complex cases from my own clinical practice. Each case is anonymized in identifying
details, but incorporates real case outcomes that are not fictionalized. Sometimes
more than one case is combined into a single case. Hopefully, you will recognize many
of these patients as the same as those you have seen in your own practice (although
they will not be the exact same patient, as the identifying historical details are
changed here to comply with disclosure standards and many patients can look very much
like many other patients you know, which is why you may find this teaching approach
effective for your clinical practice).

I have presented cases from my clinical practice for many years online (e.g., in the
master psychopharmacology program of the Neuroscience Education Institute (NEI) at
neiglobal.com) and in live courses (especially at the annual NEI Psychopharmacology
Congress). Over the years, I have been fortunate to have many young psychiatrists
from my university and indeed from all over the world, sit in on my practice to observe these cases, and now I attempt to bring
this information to you in the form of a case book.

The cases are presented in a novel written format in order to follow consultations
over time, with different categories of information designated by different background
colors and explanatory icons. For those of you familiar with Essential Psychopharmacology: The Prescribers Guide, this layout will look quite familiar. Included in the case book, however, are many
unique sections as well; for example, presenting what was on the author’s mind at
various points during the management of the case, and also questions along the way
for you to ask yourself in order to develop an action plan. Also, these cases incorporate ideas from
the recent changes in maintenance of certification standards by the American Board
of Psychiatry and Neurology for those of you interested in recertification in psychiatry.
Thus, there is a section on Performance in Practice (called here “confessions of a
psychopharmacologist”). This is a short section at the end of every case, looking
back and seeing what could have been done better in retrospect. Another section of
most cases is a short psychopharmacology lesson or tutorial, called the “Two Minute
Tute,” with background information, tables and figures from literature relevant to
the case on hand. Shorter cases of only a few pages do not contain the Tutes, but
get directly to the point, and are called “Lightning Rounds.” Drugs are listed by
their generic name, and often have a brand name mentioned the first time they appear
in a case. A generic and brand name index is included at the back of the book for
your convenience. Lists of icons and abbreviations are provided in the front of the
book.

The case-based approach is how this book attempts to complement “evidence based prescribing”
from other books in the Essential Psychopharmacology series, plus the literature, with “prescribing based evidence” derived from empiric
experience. It is certainly important to know the data from randomized controlled
trials, but after knowing all this information, case based clinical experience supplements
that data. The old saying that applies here is that wisdom is what you learn AFTER
you know it all. And so, too, for studying cases after seeing the data.

A note of caution. I am not so naive as to think that there are not potential pitfalls
to the centuries-old tradition of case-based teaching. Thus, I think it is a good
idea to point some of them out here in order to try to avoid these traps.

Do not ignore the “law of small numbers” by basing broad predictions on narrow samples
or even a single case.

Do not ignore the fact that if something is easy to recall, particularly when associated
with a significant emotional event, we tend to think it happens more often than it
does.

Do not forget the recency effect, namely, the tendency to think that something that
has just been observed happens more often than it does.

According to editorialists (1), when moving away from evidence-based medicine to case-based
medicine it is also important to avoid:

Eloquence- or elegance-based medicine

Vehemence-based medicine

Providence-based medicine

Diffidence-based medicine

Nervousness-based medicine

Confidence-based medicine

I have been counseled by colleagues and trainees that perhaps the most important pitfall
for me to try to avoid in this book is “eminence-based medicine,” and to remember
specifically that:

Radiance of gray hair is not proportional to an understanding of the facts

Qualifications and past accomplishments do not signify a privileged access to the
truth

Experts almost always have conflicts of interest

Clinical acumen is not measured in frequent flier miles

So, it is with all humility as a practicing psychiatrist that I invite you to walk
a mile in my shoes, experience the fascination, the disappointments, the thrills and
the learnings that result from observing cases in the real world.

Case Studies: Stahl's Essential Psychopharmacology: Contents

The Case: The man whose antidepressants stopped workingThe Question: Do depressive episodes become more difficult to treat and more recurrent
over time?The Dilemma: When can you stop antidepressant treatment and what do you do if medications
that worked in the past no longer work?

The Case: The woman who has always been out of controlThe Question: How do you treat chaos?The Dilemma: What can you expect from an antipsychotic in a woman with many problems
and diagnoses?

The Case: The son who would not take a showerThe Question: Will a 32-year-old man with an 18-year history of psychotic disorder
ever be able to live on his own?The Dilemma: How can aging parents no longer with the health or the means to support
an adult patient with a serious mental illness move their son towards independence
without decompensating his psychotic illness or making him homeless?

The Case: The young man with alcohol abuse and depression like father, like son; like
grandfather, like father; like great grandfather, like grandfatherThe Question: How can you help a young man who denies his alcoholism and depression?The Dilemma: Why do so few psychopharmacologists treat addictive disorders with approved
medications?

The Case: The man who kept hitting his wife over the head with a frying panThe Question: How do you treat aggressive behavior in a patient with early Alzheimer’s
Disease?The Dilemma: Can Alzheimer patients ever be treated with black box antipsychotics?

The Case: The woman with psychotic depression responsive to her own TMS machineThe Question: What do you do for TMS responders who need longterm maintenance?The Dilemma: Finding simultaneous medication treatments to supplement TMS for her
psychosis, confusion and mood disorder when ECT and clozapine have failed

The Case: The son who would not go to bedThe Question: What do you do when SSRIs and behavioral therapy fail to reverse disability
in OCD for more than 19 years?The Dilemma: How to improve quality of life for a patient with treatment resistant
OCD still living at home?

The Case: The boy getting kicked out of his classroomThe Question: What is pediatric mania?The Dilemma: What do you do for a little boy with a family history of mania and who
is irritable, inattentive, defiant and aggressive?

The Case: The sleepy woman with anxietyThe Question: How can you be anxious and narcoleptic at the same time?The Dilemma: Finding an effective regimen for recurrent, treatment resistant anxious
depression while juggling complex treatments for sleep disorder.

The Case: The young man whose dyskinesia was prompt and not tardiveThe Question: What is the cause of a profound and early onset movement disorder in
a young man who just started a second generation atypical antipsychotic?The Dilemma: How do you treat the psychotic illness without making the movement disorder
worse?

The Case: The woman who felt numbThe Question: Are the complaints of a 63-year-old woman with a complex set of psychiatric
conditions due to incomplete recovery, or to SSRI induced apathy?The Dilemma: How to have your cake and eat it, too: namely, remission from psychiatric
disorders yet no drug-induced cognitive side effects

The Case: The patient whose daughter wouldn’t give upThe Question: Is medication treatment of recurrent depression in an elderly woman
worth the risks?The Dilemma: Should remission still be the goal of antidepressant treatment if it
means high doses and combinations of antidepressants in a frail patient with two forms
of cancer and two hip replacements?

The Case: The case of physician do not heal thyselfThe Question: Does the patient have a complex mood disorder, a personality disorder
or both?The Dilemma: How do you treat a complex and long-term unstable disorder of mood in
a difficult patient?

The Case: The psychotic arsonist who burned his house and tried to burn himselfThe Question: How to keep an uncooperative yearold psychotic man with menacing behavior
under behavioral controlThe Dilemma: What can you do after you think you have blocked every dopamine receptor
and cannot give clozapine?

The Case: The son whose parents were desperate to have him avoid KraepelinThe Question: Can you forecast whether an adolescent will become bipolar, schizophrenic
or recover?The Dilemma: Should you treat symptoms empirically when the diagnosis changes every
time the patient come for a visit?

The Case: The woman with depression whose Parkinson’s disease vanishedThe Question: Can state dependent parkinsonism be part of major depressive disorder?The Dilemma: How to diagnose and treat with simultaneous antidepressants and antiparkinsonian
drugs?

The Case: The soldier who thinks he is a “slacker” broken beyond all repair after
3 deployments to IraqThe Question: Are his back injury and PTSD going to end his military career?The Dilemma: Is polypharmacy with 14 medications including multiple opiates, tranquilizers
and psychotropics the right way to head him towards symptomatic remission?

The Case: The depressed man who thought he was out of optionsThe Question: Are some episodes of depression untreatable?The Dilemma: What do you do when even ECT and MAOIs do not work?

The Case: The young man everybody was afraid to treatThe Question: How can you be confident about the safety of combining antihypertensive
medications for serious hypertension with psychotropic drugs for serious depression
in a patient with a positive urine screen for amphetamine?The Dilemma: Which antidepressants can you use?

The Case: The woman who was either manic or fatThe Question: Will patients be compliant with effective mood stabilizers that cause
major weight gain?The Dilemma: Can you find a mood stabilizer that does not cause weight gain or a medication
that blocks the weight gain of the mood stabilizer?

The Case:The young woman whose doctors could not decide whether she has schizophrenia,
bipolar disorder or bothThe Question: Is there a such thing as schizoaffective disorder?The Dilemma: Does treatment depend upon whether the diagnosis is schizophrenia, bipolar
disorder or schizoaffective disorder?

The Case: The girl who couldn’t find a doctorThe Question: How aggressive should medication treatment be in a child with an anxiety
disorder?The Dilemma: Can you justify giving high dose benzodiazepines plus SSRIs to a yearold?

The Case: The scary man with only partial symptom control on clozapineThe Question: How to manage breakthrough positive symptoms as well as chronic negative
symptoms in a 48-year-old psychotic patient with a history of homicide and suicide
attempts?The Dilemma: What do you do when even clozapine does not work adequately?

The Case: The man who wondered if once a bipolar always a bipolar?The Question:Is antidepressant induced mania real bipolar disorder?The Dilemma: Can you stop mood stabilizers after years of stability following one
episode of antidepressant induced mania without boarding a year roller coaster of
mood instability?

The Case: The 8-year-old girl who was naughtyThe Question: Do girls get ADHD?The Dilemma: How do you treat ADHD with oppositional symptoms?

The Case: Suck it up, soldier, and quit whiningThe Question: What is wrong with a soldier returning from his deployment in Afghanistan?The Dilemma: Is it traumatic brain injury, PTSD or postconcussive syndrome, and how
do you treat him?

The Case: The scatter-brained mother whose daughter has ADHD, like mother, like daughterThe Question: How often does ADHD run in families?The Dilemma: When you see a child with ADHD, should you also evaluate the parents
and siblings?

The Case: The young man who is failing to launchThe Question:What is the underlying illness and when can you make a long term diagnosis?The Dilemma: What can you do for a young adult on a tragic downhill course of social
and cognitive decline?

The Case: The doctor who couldn’t keep up with his patientsThe Question:Is cognitive dysfunction following a head injury due to tramatic brain
injury or to depression?The Dilemma: How can treatment improve his functioning at work?

The Case: The young cancer survivor with panicThe Question:Why is this patient resistant to medication treatments?The Dilemma: How aggressive should psychopharmacological treatment be in terms of
dosing and duration of drug treatment for panic?

The Case: The computer analyst who thought the government would choke him to deathThe Question: Can you tell the difference between schizophrenia, delusional disorder
and obsessive compulsive disorder?The Dilemma: What do you do when antipsychotics do not help delusions?

The Case: The man whose antipsychotic almost killed himThe Question: How closely should you monitor atypical antipsychotic augmentation in
a type diabetic with treatment resistant depression?The Dilemma: Can you rechallenge a patient with an atypical antipsychotic for his
highly resistant depression when he developed hyperglycemic hyperosmotic syndrome
on the medication the last time he took it?

The Case: The severely depressed man with a life insurance policy soon to lose its
suicide exemptionThe Question: Is unstable depression without mania or hypomania a form of unipolar
depression or bipolar depression?The Dilemma: Do mood stabilizers work for patients with very unstable mood even if
the patient has no history of mania or hypomania?

The Case: The painful man who soaked up his opiates like a spongeThe Question: What do you do for a complex chronic pain patient whose symptoms progress
despite treatment?The Dilemma: How far can medications go to treat chronic pain?

The Case: The anxious woman who was more afraid of her anxiety medications than of
anything elseThe Question: Is medication phobia part of this patient’s anxiety disorder?The Dilemma: How do you treat a patient who has intolerable side effects with every
medication?

The Case: The woman with an ever fluctuating moodThe Question: Where does her personality disorder end and where does her mood disorder
begin?The Dilemma: Can medication work for mood instability of a personality disorder?

The Case: The psychotic woman with delusions that no medication could fixThe Question: How can you weigh severe side effects with therapeutic benefits of clozapine
plus augmentation in a severely ill patient?The Dilemma: Is it possible for a patient to have better functioning even though treatment
does not help her delusions?

The Case: The psychotic sex offender with grandiosity and maniaThe Question: How to stabilize an assaultive patient with deviant sexual fantasies
not responsive to standard doses of antipsychotics and mood stabilizers?The Dilemma: Should heroic doses of quetiapine be tried when standard doses give only
a partial response?

The Case: The breast cancer survivor who couldn’t remember how to cookThe Question: What is chemobrain?The Dilemma: Can you treat cognitive dysfunction following chemotherapy for breast
cancer?

The Case: The elderly man with schizophrenia and Alzheimer’s diseaseThe Question: How do you treat a patient with schizophrenia who is poorly responsive
to antipsychotics and then develops Alzheimer’s dementia?The Dilemma: Can you give an antipsychotic for one disorder when this is relatively
contraindicated for another disorder in the same patient at the same time?

Release/Expiration Dates

Original release date: May 1, 2011

CME credit expiration date: April 30, 2014. (CNE credit expires April 30, 2013). If either of these dates has passed, please contact NEI for updated information.

PLEASE NOTE: The posttest can only be submitted online.The posttest questions have been provided below solely as a study tool to prepare
for your online submission.Faxed/mailed copies of the posttest cannot be processed and will be returned to the
sender. If you do not have access to a computer, please contact customer service at
888-535-5600.

To receive a certificate of CME credit or participation, please complete the posttest
and commitment-to-change questions along with the activity evaluation, available online
only at www.neiglobal.com/CME (under “Book”). If a passing score of 70% or more is attained (required to receive
credit), you can immediately print your certificate. There is a fee for CME credits
for this activity (waived for NEI members).

1.

A patient with bipolar disorder has been taking valproate with only partial control
of depressive symptoms, and his clinician elects to add lamotrigine. Compared to lamotrigine
monotherapy, what adjustment should be made to the lamotrigine titration schedule
in the presence of valproate?

Titration scheduled should be halved

Titration schedule should be doubled

Titration schedule should be the same as for lamotrigine monotherapy

2.

A 22-year-old man with a history of cognitive and social delay has just been diagnosed
with schizophrenia. In early elementary school his language development was normal
but he had difficulty reading and was diagnosed with a learning disability. He had
increased academic difficulty beginning in high school but did graduate and began
working at a supermarket. However, he began to exhibit difficulty functioning, including
disorganization and deterioration in communication, which led to his dismissal from
his job. Six months later he experienced a psychotic episode and was diagnosed with
schizophrenia. What pattern of cognitive functioning would you expect for this patient
over the long-term course of his illness?

Progressive decline in cognitive functioning beyond what is expected with normal aging

No further decline in cognitive functioning beyond what is expected with normal aging

5.

Which of the following are approved treatments for resistant depression?

Aripiprazole

Quetiapine

Selegiline

A and B

A and C

A, B, and C

6.

Which of the following has the least risk of causing a movement disorder?

Aripiprazole

Clozapine

Quetiapine

Risperidone

7.

Which of the following have hallucinations associated with them?

Schizophrenia

Schizophrenia and OCD

Schizophrenia, OCD, and delusional disorder

8.

When a patient is not responding to clozapine, which of the following is the best
strategy to take?

Raise the dose

Ensure that plasma levels are between 200–300 ng/ml

Ensure that plasma levels are between 400–600 ng/ml

9.

Which of the following is true regarding the use of atypical antipsychotics in elderly
patients?

Atypical antipsychotics are contraindicated in all elderly patients

There is a warning regarding use of atypical antipsychotics in all elderly patients

Atypical antipsychotics are contraindicated in elderly patients with dementia-related
psychosis

There is a warning regarding use of atypical antipsychotics in elderly patients with
dementia-related psychosis

10.

A 44-year-old woman with treatment-resistant depression is going to begin treatment
with transcranial magnetic stimulation. What is the typical duration of treatment
for this method?

2 sessions a month for 3–6 months

1 session a week for 8–12 weeks

5 sessions a week for 4–6 weeks

1 session a day for 1–2 weeks

11.

Which of the following foods should be avoided for patients taking oral doses of MAOIs?

Aged cheeses and tap beers

Processed meat and canned or bottled beers

Fresh poultry and baker’s yeast

12.

Hypertension is a contraindication for treatment with:

Lithium

MAO inhibitors

Lithium and MAO inhibitors

Neither lithium nor MAO inhibitors

13.

Cognitive symptoms of depression may best be alleviated by boosting which neurotransmitters
in the prefrontal cortex?

Norepinephrine and serotonin

Serotonin and dopamine

Dopamine and norepinephrine

14.

Before initiating venlafaxine treatment, and throughout the treatment, you should
monitor for:

Change in blood pressure

Diabetes

Parkinsonism

Weight gain

15.

A 33-year-old woman with a major depressive episode is prescribed paroxetine. Three
weeks later she buys $40,000 worth of clothes and electronics in three days; her boyfriend
says that she is staying up all night claiming to be working on “a project that will
change the world.” She is diagnosed with antidepressant-induced mania/hypomania. Guidelines
for treating antidepressant-induced mania/hypomania are:

Prescribe a mood stabilizer for one year, then discontinue gradually while monitoring

Prescribe a mood stabilizer indefinitely

There are no clear guidelines

16.

The presence of diabetes is a contraindication to treatment with:

Clozapine

Olanzapine

All atypical antipsychotics

No atypical antipsychotics

17.

Which of the following is true regarding medication use for bipolar disorder during
pregnancy?

Lithium has known teratogenic effects and is not a preferred treatment

Valproate has known teratogenic effects and is not a preferred treatment

Olanzapine has known teratogenic effects and is not a preferred treatment

A and B

A, B, and C

18.

Which of the following classes of medications have black box warnings stating that
they should not be prescribed to children under the age of 12?

Antidepressants

Antipsychotics

Benzodiazepines

A and C

None of the above

19.

The course of bipolar illness in children and adolescents as compared to adults generally
consists of:

Acute episodes characterized by irritability

Acute episodes characterized by euphoria

Chronic symptoms characterized by irritability

Chronic symptoms characterized by euphoria

20.

When a patient has mood symptoms resulting from a personality disorder, medication
treatment by itself is not likely to provide substantial benefit.

True

False

21.

Chronic pain with no known injury is most likely attributable to:

Central sensitization of brain and spinal cord pain circuits

Somatization of psychological symptoms

Either of the above

22.

I commit to making the following change(s) in my practice as a result of participating
in this activity:

I will stay up-to-date on the risks of using atypical antipsychotics in the elderly.

I will consider atypical antipsychotics in difficult-to-treat aggressive cases after
discussing the risks and benefits with the patient.

I will remain up-to-date on the research discussing how to treat behavioral symptoms
associated with dementia.

A and B

A and C

B and C

I will make all of the above changes (A, B, and C).

I am already doing all of the above.

23.

I commit to making the following change(s) in my practice as a result of participating
in this activity:

I will consider prescribing antidepressants to children if the case warrants it.

I will follow up religiously with patients who are on antidepressants and may be suicidal.

I will review all medication dosing instructions with patient and family to ensure
proper compliance.

A and B

A and C

B and C

I will make all of the above changes (A, B, and C).

I am already doing all of the above.

24.

I commit to making the following change(s) in my practice as a result of participating
in this activity: